Instructional Programs Influencing the Enhancement of the Knowledge Required by Volunteers in Disasters: A Systematic Review

Objective: To determine the instructional programs required by volunteers based on the studies carried out worldwide. Methods: A systematic search was carried out by PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science and ProQuest databases between January 1970 and the end of June 2019. The articles were selected based on the keywords chosen by the author. In the end, the volunteer’s instructional titles were extracted from the articles in disasters. Results: Eleven articles were chosen for final analysis after studying the titles, abstracts, and complete articles texts which 45 instructional titles were extracted. The most frequent scales in terms of repetition were ethics, kinds of exercises, personal protection instruments, general hygiene, awareness of certain disasters, accident command system, disaster triage and emergency planning. Conclusion: Governments should offer programs that can best serve the improvement of their performance by considering the daily increasing growth in the number of volunteers and in natural and manmade disasters. Universities and schools play determinant roles in this regard. It is hoped that the present study findings can be effective in codify an efficient instructional program for elevating the performance of the volunteers by taking part in disasters response.


Introduction
P eople who lives in developing countries are usually more influenced by natural disasters. In fact, the majority of mortalities and casualties occur in these countries [1]. Human beings suffer from natural and manmade disasters because these accidents cause homelessness, food shortage, outbreak of diseases, and emergence of psychological and mental ailments [2]. Natural disasters leave damages behind more in developing countries since there is no comprehensive plan to respond an emergency condition in these countries [3,4]. Various groups usually engage in relief and rescue operations as volunteers in natural and manmade disasters.
Volunteer refers to an individual who tends to spend time for a good deed without expecting any money in exchange [5]. Volunteers are expected to prove a more accentuated presence in disasters' management and their risks reduction in international levels [6]. Volunteers are expected to exhibit a more highlighted presence and role in the future disasters according to the enhancing need of the society's resilience. However, the volunteer's role has undergone notable changes in the 21 st century [7]. Volunteers play vital roles in responding and monitoring during disasters. For example, volunteers were actively participated in preparation of risk maps for flood-prone regions in Queensland State of Australia between 2010 and 2011 [8]. Digitalization of the volunteers' presence and activity is also a great importance in disaster management by considering the modern technologies growth in the contemporary world [9,10]. Volunteers' activities might last from days to months for disaster management [11]. Volunteers can obtain fast information regarding flood through local environments. The information prepared by individuals is readily discernable by the volunteers who can provide managers with precise and reliable information [12].
Volunteers are recommended to be trained; therefore, their capacities can be put into practical use at the time of disasters when there are few or no professionals [13]. The relevant instructional subjects in regard to save drowned persons are including Cardiopulmonary resuscitation (CPR), injury and fracture management and emergency bleeding control. The instructional needs should be matched with the organization vista and mission as well as with the local government's support. They should be adjusted to the local values, rites, and customs as well [14]. The disaster-responding volunteers might have special psychological health needs. Thus, certain interventions have to be taken into account for psychologically supporting the volunteers who have stress and worries and are not mentally prepared [15].
Overall, the majority of countries around the globe are disaster-prone. Volunteers pervasively and comprehensively attend various disaster scenes but they usually have relatively low knowledge and awareness. The present study aims to determine the instructional programs required by volunteers based on the studies that have been carried out worldwide.

Eligibility Criteria and Search Strategy
The study protocol was first registered in PROSPERO database with the identification number CRD42020187680. In this systematic review, the search method was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A systematic search was conducted in peer-reviewed and English texts from January 1970 to June 2019 which were related to the study question; i.e., "what instructional programs are required to enhance the volunteers' knowledge and awareness in disasters?". At first, a general and swift search was carried out in Cochrane Library Database to ensure that no systematic reviews were carried out in this regard. No similar articles were found. Then, searches were conducted in electronic databases like PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science, and ProQuest. Moreover, additional searches were made in grey literature includes books, internet websites, conference articles and dissertations. The group of using words was made the operator "and", and it was considered as separate concepts. Furthermore, operator "or" was applied between the synonymous words. Searches were conducted in the titles, abstracts, and keyword of the articles. In PubMed database, MESH term was utilized for finding the articles. The employed search strategy has been shown in Table 1. Since there was no comparison group in this study, "C" or the very comparison group was not taken into consideration in population, intervention, comparison and outcomes (PICO). The search keywords were selected by the researcher. In the end, the factors were extracted from the selected articles. In the next stage, a complete list of the references was prepared from all the articles and the articles' titles were investigated by the researchers. Accordingly, the articles irrelevant to the study goal were eliminated. For more assurance, all search stages were replicated twice. Endnote, version X8.1 was the software of choice for managing the resources.

Inclusion Criteria
Firstly, the keywords related to instructional programs required by the volunteers in disasters had to exist in the titles, abstracts and keywords of the searched articles. The related works' abstracts were studied and finally the whole articles were analyzed by using assessment tools. The searches in the present systematic review were carried out for the articles published from 1970 to the end of June 2019. Unpublished articles (grey literature), protocols, 107 conference articles, guidelines, instruction manuals, and credible organizations' reports were explored, as well. The review, qualitative and quantitative articles were selected. Peer-reviewed articles were also selected.

Exclusion Criteria
The articles of irrelevant variables to the study question were omitted.

Screening
At first, all articles title were investigated by the author from the databases. The articles that met the inclusion criteria and were related to the study question were chosen. In the next stage, the selected articles' abstracts were read by the author. Next, the parallel articles of the study goal and inclusion criteria were selected and the articles perfect texts were read and evaluated by the author. In the end, the instructional titles' articles required by the disaster's volunteers were selected. PRISMA guidelines were employed to evaluate the articles. Documentation and publication biases were also taken into consideration and the articles with a high rate of documentation were carefully evaluated. Quantitative articles were evaluated with strengthening the reporting of observational studies in epidemiology (STROBE) checklist, qualitative articles with consolidated criteria for reporting qualitative research (COREQ) checklist, mixed methods articles with consensusbased Standards for the selection of health status Measurement Instruments (COSMIN) checklist and review articles with PRISMA checklist. The entire aforementioned stages were repeated twice.

Data Extraction
The required information was extracted based on a summarization and data gathering form after carefully reading the articles. The information includes the corresponding author, study population, study sample size, study period, study design, data gathering instrument, study method, results, limitations, conclusion and instructional titles required by the volunteers. The summarization forms were completed for each of the selected articles. Two researchers completed all the forms and exhibited their tabular form following the investigation of all the articles. Finally, other study's researchers offered their ideas regarding the conflict issues in the articles. The forms were composed in Microsoft Word, version 2016.

Results
After searching the databases, 12712 articles were selected. Of these, 4026 were omitted because they were found repeated in various databases. After investigating 8686 article titles, 8601 were excluded because they were found not to be consistent with the study goal. The 85 remained articles' abstracts from the previous stage were studied and 71 articles were excluded due to not being relevant to the study goal. Eventually, 14 complete article texts were selected for this study. In the end, 11 complete articles' texts were found to be perfectly matched with the study goal. The articles selection process has been depicted in Figure 1. A summary type of the extracted articles has showed in Table 2. Accordingly, two articles included a mixed method research, six articles were quantitative and three articles were review studies. The results analysis obtained from the selected articles has showed in Table 3. After the final analysis, 44 instructional titles were extracted. The most frequent criteria of repetition were ethics, exercises' different types, personal protection instruments, general hygiene, awareness of special disasters, accident command system, disaster triage, emergency planning and disaster triage.
After reading the perfect texts of the 11 articles, the results were summarized in Table 4. The information includes title, corresponding author, study population, sample size, country, accomplishment time, data gathering instrument, method, results, limitations, conclusion, and instructional title (Table 4).

Discussion
The present study aimed to extract the instructional titles required by volunteers in disasters of various countries around the globe. According to the results, six cross-sectional studies were dealt with the investigation of knowledge, awareness and instruction of the volunteers through questionnaires. Indeed, two combined articles were dealt with the issue through interviews, modeling methods, questionnaires and focus group sessions. Three review studies were carried out, as well. Out of the extracted studies, six were conducted in the US. After that, the highest studies' frequency was related to Indonesia, Thailand, Japan, China and Australia since devastative natural disasters had occurred in these countries and volunteers played more accentuated roles in the rescue and relief operations.
Considering the fact that the society's resilience is enhanced in the course of disasters, more accentuated roles are expected to be exhibited by the volunteers in disasters. However, the roles of the volunteers have undergone more considerable changes in the 21 st century. In Australia, five strategies have been taken into account for emergency conditions management includes the strategies development of flexible volunteers, corroboration of the active and always ready volunteers, surge capacity,   digitalization of the volunteers, and growth in the volunteers' skills and society-oriented interventions to reduce disasters [7]. Certain strategies should be taken into consideration for successful and effective presence of the volunteers in various countries. In this context, digitalization and online management of the volunteers are amongst the most important programs since many of these instructions can be offered through the internet and social networks. Vermont's Department of Healthcare (VDH) in the US has codified an instructional program with three goals including background information about general hygiene, preparation under emergency conditions and practical instructions to the volunteers. The main components of the instructional programs are goals and capacities of general hygiene, an introduction to preparation under emergency conditions, exercises, personal and familial preparation exercises and guidelines. In order to increase the volunteers' potentials, multivariate instructional programs were implemented online, by email, and in person [19]. In this context, the healthcare and treatment instructions are the most essential instructions required by the volunteers because a large number of people who need help will become inflicted with injury and damage. Initial precaution, disaster triage, search and rescue, logistics and communications, and organizational team are amongst the most important titles that should be taught to the volunteers. However, few studies have been conducted on the knowledge and skill of emergency care in disasters. It has been suggested that the volunteers should be trained in the same way that their capacities can be utilized when there are few or no professionals present on the disasters scene [13]. Start triage should also be taught to the volunteers who pertains to triage in disasters.
Moreover, the volunteers who get present for rescue and relief in disasters should be able to restore themselves psychologically and physically. Furthermore, governmental organizations should provide the damages' information to predict the disasters course as well as the prevention instruction of disaster occurrence for the local residents. Residents should also prepare the incident map and disaster prevention with the assistance of other habitants. In the end, enhancement of the local associations' activities might increase the residents' cooperation [21]. The volunteers' needs for psychological health in response to disasters are of great importance and should have be taken into account by policymakers. The volunteer's disaster-responding might have special psychological health needs. Thus, certain measures should be taken into account for psychologically supporting the volunteers who have stress and worries and are not mentally prepared [15]. In this regard, appropriate participation of sophisticated psychologists and psychiatrics can be contributive in disasters. The volunteers attending disasters should have a good deal of knowledge and awareness; therefore, they can provide proper response to this kind of incidents. Universities are important environments for performing voluntary interventions. A private organization volunteers who are willing to help in the course of natural disasters and have certain skills can also be useful in damages reduction. As for the settlement of the volunteers in the course of disasters, things should be learnt and instructed. The disasters instructing preparation is a rational step for the volunteers in universities [20]. The volunteers' participation in academic environments before the occurrence of incidents contributes to their higher coordination.
In response to natural and manmade disasters, the governments should offer instructions to improve their performance by considering the daily increasing growth in the number of individuals who taking part. Universities and schools also play determinant roles in this respect. It is hoping that the findings of this study can be effective in codification of an efficient instructional program for enhancing the volunteers' performance in respond to disasters.
Considering an effective and decisive presence of volunteers in natural and man-made disasters and their awareness of vital issues such as self-protection with personal protective equipment (PPE), incident command system (ICS) and first aid measures can help save the lives of the injured or sick as was observed in the COVID-19 crisis.
Planners and policy makers of relief organizations includes the Red Crescent, the Red Cross, and the Ministry of Health should formulate a training program to help the integrate maximize training, performance and effectiveness for volunteers. It has reached the ultimate goal of disaster management which is reducing deaths and injuries.

Study Limitation
One of the limitations of this study was using only English made articles. The search was also very extensive and covered a wide spectrum which led to the selection of a large array of articles.